Town Square

Eshoo: No plans for health care town hall?

Original post made
on Aug 17, 2009

As people pack town hall meetings across the country on plans for health care reform, Rep. Anna Eshoo, D-Menlo Park, has not announced plans to hold a similar meeting with her constituents during Congress' August recess.

Posted by Michael Perez
a resident of Menlo Park: The Willows
on Aug 17, 2009 at 1:48 pm

As a small business owner, I am particularly interested to know where the Congresswoman comes down on the issue of requiring small businesses with payrolls of 250K to pay between 2% and 8% of their revenue for health insurance coverage. Her staff didn't know the answer to this when I stopped by last week, but they said they would "get back to me."

Posted by Roger von Oech
a resident of Atherton: West Atherton
on Aug 17, 2009 at 3:46 pm

I'd love to attend a Town Hall meeting hosted by my congresswoman, Anna Eshoo, to hear what she and my fellow 14th District constituents (both pro and against) think about the health care bills currently being discussed in congress.

I've contacted her Palo Alto office five or six times about such an assembly since July, but her spokesmen have been vague (though courteous).

Anna needs to reconsider and hold a town hall meeting on this topic and do it soon. A live, face to face exchange is what we want, not a series of e-mail Q and A's to hide behind. Talk with us and hear us out, Anna--you work for us.

Menlo Park and Palo Alto are so filled with Obama adoring fans that any socialist scheme he proposes will get glowing support by the vast majority of Anna Eshoo's consituents. And Eshoo has nothing to fear by hosting a Town Hall Meeting because the majority of Menlo Park and Palo Alto voters views are so divergent from the mainstream political thought in this country that a Town Hall meeting would be nothing more than a lovefest.

Some friends and I were going to go to Woodstock. Unfortunately I could not get off work. I lived in Maryland at the time and it was only a 6 hour drive. So they went without me. Tickets were only $8 for each day (Friday, Saturday, & Sunday in August) . My friends could not get within 5 miles of the place and did not hear any music at all. It also rained like hell that weekend. So I wasn't too disappointed

I went to the Atlanta International Pop festival the next year and saw Jimi Hendrix's last live performance there on July 4. Two months later he died in London.

Some really good music for the time. If the town hall meeting could score some of those bands I would not eschew Eshoo.

Anna simply doesn't care what voters in her district think as she has a totally safe seat. Witness her contempt of basic democracy by refusing to allow voters to ask questions at her upcoming rail town hall.

Posted by Pat
a resident of another community
on Aug 19, 2009 at 8:10 am

Anna aparently thinks that High Speed rail is more important than Healthcare.. It can be when a train going 500 miles an hour crashes into the proposed Vegas to LA train causing many to be sent to the Hospital . High Speed rail to LA is not necessary when you can fly there in less than an hour

Posted by SamA
a resident of Menlo-Atherton High School
on Aug 19, 2009 at 2:15 pm

So apparently Anna's answer to this criticism is to hold a "telephone meeting" on healthcare. See here: <Web Link;

A "telephone meeting" is an oxymoron, like "military intelligence" or "jumbo shrimp." (If any kids are reading this, that's a fancy way of saying "there's no such thing.") Most of her constituents can probably tell the difference between a "meeting" and a "telecon". In fact, a bunch of us have endured long plane trips in order to hold a "meeting" rather than a "telecon".

The fact that she's deliberately trying to confuse us about the difference tells us something about her ... and about what she thinks of us.

Wow! I could have sworn I saw an aritcle about Anna and her phone in town hall meeting..the one she announced at the last minute (12:30ish)..the one you couldn't participate in unless you called in to register by 3ish, a time when of course so many hard working tax payers are home from work and able to participate. The aritcle is gone...poof! Not on the Almanac or PA Weekly now, just on the Mtn View site. Too bad her meeting wasn't on the local cable tv.

Posted by Vicki
a resident of Menlo Park: The Willows
on Aug 20, 2009 at 7:17 am

I hadn't read about the meeting ahead of time, but I got an automated call that brought me into the meeting after it started. (This has happened with other meetings too.) I listened for awhile, and one of the questions was about small businesses. I think what she said was that the current proposal is that businesses with payrolls of less than $500,000 will be exempt. Then there is a ramping up of contribution for business between $500k and $750k. But I didn't catch the amount of the proposed contribution for health care for the businesses that will be expected to contribute.

I don't know why I was called - maybe because I've written letters to her office a few times.

Posted by not a fan
a resident of Menlo Park: Downtown
on Aug 20, 2009 at 9:11 am

From what I can tell of her website, you cannot choose to join the meeting, you can only leave your phone number and hope to be called. Presumably her staff vets the list, and if you look like a troublemaker you will not be invited to join.

There was very little notice of yesterday's meeting, so only voters who had previously registered on her site were called. But she has three others coming up.

There was another thread yesterday; I posted on it. Maybe the Almanac was embarrassed that they didn't inform us of the deadline until after it had passed?

Believe it or not I was called by Anna Eshoo's office to join the meeting. It was probably computer generated. Anna is going to support the single payer plan. She was only highlighting the good portions and neglecting the bad portions. Everyone was polite.

This is a very bad plan. It will transfer health care from the elderly to illegal aliens and young people who don't want to pay for health insurance.

The current system has some serious flaws. Such as fraudulent claims against insurance companies, and insurance companies denying valid claims. This should be answered by having more oversight in the current health system over any party who tries to scam the system.

But to intorduce a socialist healthcare system into the United States is about the worst thing that could happen. People in Canada have 4 times the death rate from cancer due to rationed health care.

And mark my words the Obama health plan is rationed healthcare with the elderly taking the biggest hit. You can not expand the base of patients with the current level of doctors and not have rationed health care.

Also, people will be detered from going to medical school when they realize that their standard of living will drop precipitously if they become doctors and have their judgment second guessed by some faceless inept bureaucrat who does not have an inkling about what proper medical care is.

It is interesting to observe that when socialists are called socialists they follow Saul Alinsky's Rules for Radicals and try to deride the truth tellers. But people are smart and realize that Barack Obama is a dedicated and committed socialist. While his socialism may have traction in Menlo Park it won't sell in Peoria. And there are lot more Peorias than Menlo Parks.

Posted by Lea
a resident of another community
on Aug 20, 2009 at 12:49 pm

Rep.Anna Eshoo did have a virtual town hall meeting last night, where people could participate over the phone. I found it very informative and much more productive of the town hall meetings FoxNews covers.

In which socialist country do you spend most of your time. It would be much easier if all the socialists in the United States move to a socialist country rather than trying to make the United States one.

Do you mean books like Das Kapital, The Communist Manifesto, and the Long March. No thank you!

Try reading Mark Levin's Book Liberty & Tyranny or his book Men in Black. Both were resounding best sellers on the New York Times Best Sellers List.

Today August 20, 2009 4 of the top 5 books on the New York Times Non-Fiction List are written by conservatives. Only # 2 is not written by a conservative; but it is politically neutral. The top 5 Non-Fiction books according to the New York Times are:

Posted by Hank's Reality Check Nighmare
a resident of Menlo Park: other
on Aug 20, 2009 at 6:49 pm

Hank,

Both progressives and regressives (like yourself) donate money to their "worthy causes", with the difference being that progressives consider charities to be a worthy cause, while regressives view buying other regressives' books as their worthy cause.

And by the way, isn't it just a wee bit ironic that you are touting something from the New York Times? When is the WSJ going to come out with their own list?

Progressive is just a code word for socialist just as fellow traveler is a code word for communist. Progressives don't dare reveal who they really are so they use seeminingly innocuous code words such as "progressive" to inveigle people into supporting socialist programs (though they are never promoted as such).

A progressive's duty is to dismantle capitalism and replace it with regressive socialism. So progresives, in reality, are actually regressives. Socialism has proven, time and again, to be an anchronistic economic system where people are disincentivized to be creative. The end result is a decaying society.

We Capitalists reject "From each according to his abilities and to each according to his needs" because it encourages sloth and robs the people of their spirit.

Arthur C. Brooks, a professor at Syracuse University and registered independent wrote a book entitled Who Really Cares: The Surprising Truth About Compassionate Conservatism." The surprise is that liberals are markedly less charitable than conservatives.

The book's findings:
Although liberal families' incomes average 6 percent higher than those of conservative families, conservative-headed households give, on average, 30 percent more to charity than the average liberal-headed household ($1,600 per year vs. $1,227).

-- Conservatives also donate more time and give more blood.

-- Residents of the states that voted for John Kerry in 2004 gave smaller percentages of their incomes to charity than did residents of states that voted for George Bush.

-- Bush carried 24 of the 25 states where charitable giving was above average.

-- In the 10 reddest states, in which Bush got more than 60 percent majorities, the average percentage of personal income donated to charity was 3.5. Residents of the bluest states, which gave Bush less than 40 percent, donated just 1.9 percent.

Austin, Texas, voted 56 percent for Kerry while he was getting just 38 percent statewide,is ranked by The Chronicle of Philanthropy as 48th out of America's 50 largest cities in per capita charitable giving.

Hank's Reality Check Nighmare, I am flatered that you think I control editorial policy at the Wall Street Journal But in reality, the WSJ doesn't even know who I am. I apologize, but you are going to have to direct your question regarding Book lists to the WSJ. I am sorry that I can't help you.

Posted by Barbara
a resident of another community
on Aug 21, 2009 at 9:30 am

I'm all for socialized medicine. Everyone receives medical care and it's cheaper. You don't want to be paying those absurd hospital rates when it's not necessary.

We all live in this SOCIETY so therefore we need to support each other. That's what socialized medicine is all about folks. It means you don't have to mortgage your house or file bankruptcy to pay your medical bills.

Posted by Anna
a resident of Menlo Park: University Heights
on Aug 21, 2009 at 10:40 am

To anyone who snarls and bares his teeth at the mention of "socialized medicine," I would ask: Were you the beneficiary of socialized education? Did you ever attend public elementary school or high school? Do your kids attend public school?

Can you explain the difference between the government supporting the public schools so that all Americans can be educated, and the government supporting health care so that all Americans can receive the medical care they need, the care that could make the difference between life and death?

Are the people who are upset about "socialized medicine" upset about our "socialized fire department"? When you need the fire department, you call 911 and they show up! Most of us hopefully never need the services of the fire department but I don't hear anyone complaining about paying taxes for it.

This whole debate about health insurance is missing a fundamental point: using an actuarial system for health insurance doesn't work. Actuarial systems work great for things like auto insurance, because insurance companies can and do seek out safe drivers to insure. Safe drivers cost insurance companies less money. I've been driving for decades and have never had an accident or submitted a claim. But actuarial systems don't work for health insurance because sooner or later, we all die! And most of us get sick beforehand. There isn't any way for insurance companies to seek out the good risks without actively discriminating against people for getting sick. Discrimination against sick people is pretty repugnant, and we need to stop doing it. So a risk-pooling system, where everyone is covered and gets health care when they need it, is a much better way to go.

Posted by WhoRUpeople
a resident of another community
on Aug 21, 2009 at 2:03 pm

Being a somewhat conservative republican living in a geographic region dominated by fairly liberal democrats, I am quite used to being in the minority on most issues that come across this blog. That having been said, and fully realizing alot of folks will tell me to "stifle myself", I feel compelled to say two things. First, regarding Ms. Eshoo-- the person who mentioned in their post that her seat isn't threatened and therefore she doesn't need to take a risk and engage the public in an open debate, you are absolutely correct, but don't blame her, blame the party-line voters--as you can for the problems in Sacramento as well. Second, on the subject of universal health care--I personally support the need for a sensible and affordable system in this country and don't believe it should be viewed as a liberal or conservative issue or that those who are passionate about it should be labeled "socialists". BUT!-folks, with our economy weakened and with all of the money being spent to "stimulate" it (rather, in my opinion, than letting capital markets adjust as capital market always do), now is not the time to take on the cost of such an aggressive and expensive program. The fact that Obama has made this an issue now is what scares me most relative to his inexperience. We are going to have to print money (that means inflation) for generations to pay for this wonderful social experiment we've unleashed on the country.

Posted by fact checker
a resident of Menlo Park: other
on Aug 21, 2009 at 2:26 pm

As to Hank's "Reality Check Nightmare" regarding charitable giving nationally, I just checked the Chronicle of Philanthropy's data and they said that although:
" Taxpayers in rural southern and western states give the highest percentage of their earnings to charity... a Chronicle analysis of newly released federal data shows that when the higher cost of living in urban states like New York and Illinois is taken into account, residents of those states donate a much larger share of their estimated disposable incomes..." [And those incomes are significantly higher figures than in the rural south and western states' folks incomes -- so on an absolute dollar giving basis, those in urban "blue" states like NY, Illinois and I dare say, CA, are giving the lion's share of the actual total dollars going to charity.]

So what's the point???? There is no way charitable giving is going to get us out of this health care hole, anyway - so all this seems irrelevant. Virtually everyone agrees that the status quo on Health Care is not sustainable and we are the only industrialized nation not to have some safety net for health care that's available to all. We currently rank 37th or so in the world in quality of care, with among the highest costs. We're America - we can do better than this!

Those who believe in markets should not be afraid of added competition from a public option or coops that could bring all premium prices down and incent greater cost controls due to competition -- isn't that findamental to capitalism (competition)?

I like the points about public schools (or public roads which are mostly paid for by taxes) as not being similarly labeled as "socialied" in Hank's negative sense but that't what they really ARE. Just as there are still private schools, and privately funded roads that are dedicated to the public thereafter, and things like Fed Ex in ADDITION to those public options, so there would be private options still available for health care (and in fact there are lots of compaies making money on supplemental coverage for those already under Medicare who want and can afford to do so).

Allowing everyone the option to participate in something that would be like Medicare or the health plans provided to all members of COngress seems like a reasonable solution to dealing with the 47M people who are not insured and providing security to those of us who could be denied coverage (eg. due to preexisting conditions etc)

In fact, in 1964 before Medicare was created, there were similar percentages of uninsured seniours over 65. That was considered immoral to have happening, and despite it's flaws, I don't see anyone out there saying we should take away Medicare...

Get real. Let's focus on what the GOAL is here. This is the SAME thing. Time to do it and join the rest of the civilized world and recoginze that there is moral issue here. (Hint: 2/3 of the bankrputcies in the US are due to medical costs. Something is really wrong with this picture.

Its too bad when the Chroncile of Philanthropy cited the statistic of the higher cost of living did not take into account the much higher wages. In Connecticut the average teacher salary is paid $57,760. In South Dakota the average teacher salary is $34,039.

Cost of living does not tell the whole story. It must be taken into context with average salary. Leftists love to distort figures. The indisputable fact is that conservatives donate a greater percentage of their adjusted income to charities than liberals do.

Oh goody goody! Hank just gave me something else to LOVE to do! From now I will distort figures AND LOVE IT! I'll put that down on my list of things I LOVE to do, under tie-dying my t-shirts, making hashish brownies, drinking kool-aid, reading Das Kapital, cavorting with union subversives, worshiping Trotsky, and eating my babies.

Posted by Phil Palminter
a resident of another community
on Aug 23, 2009 at 6:36 am

Put Democrats here, Republicans there.

Increasingly,it is apparent that a two-state solution is the only viable solution.

No, I am not talking about Israel and Palestine. I am talking about Progressive Liberal Democrats vs. Republicans.

We should divide our country in two: Progressive liberals can live among themselves, patting each other on their backs, providing social services for all comers and taxing high income individuals and evil corporations for the sin of making a profit.

Conservative Republicans can live together as well, with a limited government and safety net, low taxes and a culture of personal responsibility and entrepreneurship.

The labeling of the bills under consideration as Socialist is just diverting attention from discussion we should be having about whether the bills actually begin to solve the serious problems in our system today.

As I see it, the problems result from a failure of our current system, which is largely built around the "for-profit, private insurance company-provided" health care model. Because it is profit-driven, the companies have every incentive to jack up the cost of coverage, deny coverage to those who are or might become sick, and limit benefits to those they do insure. As a result, 45 million Americans have no health insurance at all, with predictably deadly results.

Those of us who have insurance pay nearly twice as much for our health care as citizens of other industrialized counties. Yet we have much poorer health outcomes in terms of most standard measures. Worse,62% of all personal bankruptcies in the US are the result of medical expenses and 1.5 million families lose their homes each year to foreclosure because of medical costs, situations that citizens in other countries can hardly believe.

It seems to me that the private insurance model has had 50 years to prove that it is the most efficient way to deliver medical care to the most citizens at the least cost and it has failed decisively in all regards. It was obvious to Congress in 1964 that private-insurance was failing to deliver health care elderly people and Medicare was created. It's time for Congress to recognize that private insurance continues to fall woefully short and to provide a medicare-like program for the rest of us.

You don't have to take the word of the vast majority of citizens in other industrial counties that a single payer-type system works. Just talk to the elderly in our own country - even the conservative Republicans have been adamant that Medicare is a superior system and the Congress better not mess with it.

Posted by Concerned Parent
a resident of Menlo Park: The Willows
on Aug 24, 2009 at 1:16 pm

A few comments on health care:

Face it everyone, we cannot have all health care for all people all the time. And keep it revenue neutral.
At present, we have doctors doing all sorts of great things (diagnostic scans, fancy procedures, etc.), pharma companies developing newer and improved drugs (at great cost) and everyone wants access to everything independent of the cost.
To posit that you can cover more people at lower cost without cutting back on what is "delivered" defies any law of economics or common sense.
There is probably a way to create some improvement in efficiency, but it will cost a fair amount to truly find the right approach across all the various places where health care is delivered. What works for Mayo and Cleveland Clinic may not work for rural AMerica. Somethings may not be efficiently scalable. Just as there are claims that people die today from lack of health insurance, there will likley be people who die in the future due to decisions about what tests are coverable or not. Medicine is just that way, decisions made for a group may appear good but have an adverse impact on an individual (e.g. vaccines).
As far as end of life care, it is quite true it is expensive, and many stats are quoted about the percentage of cost expended in the last few months of someone's life. The problem is that it is only retrospectively clear what the last three months of someone's life were. Prospectively it is very difficult. There are likley some elderly folks who would prefer not to be put on a ventilator, but there may be 90-year-olds who are physiologically more like 65-year-olds and would not only tolerate an expensive cardiac bypass, but would truly benefit from it. In practical terms, it is very difficult to predefine what you wouldn't do. Hence, the fear of future rationing is not unreasonable, independent of party. Similarly, fears about sustainability should be real independent of party.
Prevention has been touted as a great cost saver, however there are problems there as well. First there is the cultural problem, the US has always had a problem with a long term preventative approach preferring to just get a pill when there is a problem. Assuming you can incent people to use preventative approaches, that will not be free and it may uncover diseases earlier, but say with diabetes, may delay, but will not prevent complications forever. Hence, you may end up with costs going up. That's not to say this shouldn't be done, only that assuming cost savings here may be wishful thinking.

I could go on, but have one more point for those in this debate. When life expectancy numbers are used to make statements like we pay twice as much but get bad results, it is important to keep in mind the difference between association and cause. It may be true that the US spends more than other countries yet has a lower life expectancy. However, one needs to keep in mind that health care is one component (hopefully contributing in a positive way) to life expectancy. The average number is decreased by infant mortality, deaths in childhood, etc. Hence, it is possible to have a markedly better result in treating lung cancer, extending patient's lives on average, by say 3 months, but have a small impact on the overall life expectancy number. On the other hand, the death of a premature infant (say a premmie who might have been aborted or not treated aggressively in an NICU in another country) or a young adult (say from a gunshot wound from a gang related shooting), will impact these numbers heavily. From what I've seen, infant mortality is something that is counted in a variety of ways and it may be that by aggressively caring for premmies, they are counted as live births, and if they die subsequently, they skew both infant mortality numbers as well as life expectancy numbers compared to a system in which they were "stillborn".

I've heard that about 30% of the insurance premium I and my company pay to the insurance companies is spent on advertising, profits that go to share-holders and CEOs, and administrative costs aimed at screening out "unsuitable" customers or restricting coverage/benefits to customers who make claims (why these people aren't called bureaucrats standing between me and my doctor I don't know). If half the $2.5 trillion spent on health care each year in this country is through private insurers, then we're talking hundreds of billions of dollars being spent to improve the company bottom-line and not on providing health care to Americans. Seems to me that these "profits" can go a long way to covering the added expenses anticipated in moving to a new and better system.

The National Health Coalition estimates the US spends $650 billion each year "above what we would expect to spend based on the level of U.S. wealth versus other nations". There is clearly more than enough in savings to be wrung from the system to cover the increased costs of insuring all our citizens.

Posted by Concerned Parent
a resident of Menlo Park: The Willows
on Aug 24, 2009 at 1:38 pm

Steve,

Medicare is a big part of the problem. People love it because they get a lot more out of it than they pay into it. The rest of us who pay taxes and have our own insurance pay more because Medicare runs at a loss. Add to that the fact that hospitals charge more to non-MEdicare patients to make up for low Medicare reimbursement rates. Are those rates set by the market, no, they are dictated to providers as a take it or leave it. I'd like a system where I received benefits double what it cost, but that's nto a sustainable model, hence the accumulated $30 trillion unfunded liability for Medicare.
And just as there has been hyperbole on the right (the whole end of life debacle is an unfortunate commentary on how poorly the US deals with that issue in general), but the left has also been irresponsible in the use of numbers in this debate. The numbers put out in terms of uninsured (called 47 million, then called "almost 50 million") are based on counting people who qualify for public programs who haven't applied, young people who appear to have means to pay for insurance, but choose not to, illegal aliens (who will need to be cared for in any system whether the bill funds it ot not), and people who lose job-based insurance for any period. Now, it is fair to argue that everyone should have access to medical care, but even with a plan with a public option will still require people to sign up. And though they will need to be treated (independent of what any final bill says, I can't imagine that hospitals ERs will have a patient show up in an ambulance and deny care in the absence of an ID card), illegal aliens will not be able to be officially in the system (politically it's too hot).
As far as the numbers on bankruptcy and foreclosure, I believe the frequently cited study had some methodological problems. THe author is certainly not free from bias (having long advocated a single payer option there is some interest in the outcome). Additionally, the study basically looked at all forclosures and bankruptcies and looked to see how many had some outstanding medical bills, not whether those bills were a significant cause in the forclosure or bankruptcy. Again, it is easy to say that someone shouldn't lose their house if they get sick, it is not clear in these situations that the causality is that stright forward (at least not from the study). In the setting of bankruptcy or forclosure, it is not surprising that the individual would have outstanding bills of all kinds, including medical bills. It would also not be surprising for there to be outstanding home repair bills, or electronic bills, etc. One would not then conclude that those bills were the "last straw" in all cases. That's what this study appears to do.
My point here is that this sort of rhetoric is being put out there to generate a sense of crisis and if it's not looked at critically (even if does not serve the casue as well), it does the debate no service.

Posted by Concerned Parent
a resident of Menlo Park: The Willows
on Aug 24, 2009 at 2:04 pm

Steve,

As far as insurance companies, I'm not particularly a fan of them, but see them in the middle of US uncertainty about what we want. If want universal health care and coverage (socialized medicine), that is fine, but let's be clear that everyone contributes and gets access. People who are healthy don't want to pay for insurance because they aren't using it, but people who need it want expensive things covered. It's great to say everyone must be covered, but if I am a 56-year old with multiple chronic medical conditions, it's a good bet that I'll use more medical resources then a healthy 25 year old. With no risk stratification, why would anyone get "insurance" until they developed an expensive condition? To me that means we need two fundamentally different ways of dealing with health care: well care (health prevention and maintenance) and sick care (catostrophic/chronic illness). To call something insurance but not make it risk stratified seems to be redefining it.
As far as advertising/administrative costs- the only comment I can make here (and I wouldn't defend this) is that if there are a variety of different options in terms of coverage (did you want the fancy drug program, the family program, the infertility coverage, etc.), it does need sorting out. To that extent, MEdicare is easier, because there is only one program and certainly no need for advertising, but it is underfunded and has its underpayment made up for by others overpaying. IF all of it is run by the government, there is nowhere to extract the extra money.
Which leads to the issue about money spent compared to other countries. I don't doubt that we can spend less money, my point would be that we will get less than we are used to (perhaps no coverage for dialysis in the elderly, certain anticancer medicines not covered, longer waits for elective surgery, longer waits for diagnostic tests, etc.). I think quoting a large sum compared to other countries and assuming it can just be saved underestimates the cultural challenges this country faces.
ANd, somehow we never hear about tort reform. Something which could save a little immediately, but would (probably over 5-10 years) result in substantial savings as there are fewer things done as "defensive medicine". This might have the added benefit of allowing open admission of medical mistakes with continuous improvement and better outcomes/decreased costs being the result. At present, the malpractice system essentially prevents this as it needlessly increases risk and liability.

Concerned Parent -
I agree that all too often rhetoric is getting in the way of the discussion and it is best to keep focused on the facts. I will endeavor to do that, even though I clearly have a strong point of view on the matter.

I'm not an expert on health care so I use the web a lot to get informed. I didn't look into whether the National Health Coalition has a political agenda but I do find that a recent article in the American Journal of Medicine came to essentially the same conclusions (or this may be the article the NHC was referencing). I have no reason to think that a scientific journal has a political agenda or that it's reviewers and editors would permit a study reflecting personal bias to be published.

Bottom line from the journal article, which was a followup to a 2001 study, is that:
- 62.1% of all bankruptcies have a medical cause
- Most medical debtors were well educated and middle class; three quarters had health insurance.
- The share of bankruptcies attributable to medical problems rose by 50% between 2001 and 2007.

I don't think you can dismiss these results as just rhetoric intended to generate a sense of crisis. The study shows that because of health expenses, hundreds of thousands of American families each year seek bankruptcy protection (I'd add that it's because the health care delivery system in this country has failed them - though the study didn't point fingers). A 50% increase in the rate of these bankruptcies in just 6 years (and this is before the economic crisis of the past 2 years) suggests that calling it a crisis is not inaccurate.

Insurance companies concern me too. There's lots of folks who would be unemployed if Blue Cross, Kaiser, and all the others were rendered obsolete by a single-payer plan. They need to be factored into whatever solution we come up with. They're not bad people - they're just working for companies that are at cross-purposes with delivering a basic level of health care most efficiently to all Americans.

Doctors complain about the time and money they have to spend to deal with the myriad of health plans, each with it's unique coverages. I've heard estimates that doctor's spend 20% of their days dealing with the paperwork from insurance companies, not to mention the added administrative staff they have to hire to manage the claims for coverage to all the different insurance companies. It becomes especially onerous when the companies deny a payment and the doctor has to take time to justify why it should be covered. This is the bureaucrat standing between the patient and the doctor (and it usually isn't a government bureacrat). A single-payer system with clearly defined coverages will wring most of these inefficiencies from the system. This will save not just money, it will save lives when those with pre-existing conditions or other exclusions are no longer kept from getting the best treatment the doctor can recommend.

But to address your comment about the need for risk stratification: in a single-payer system people are seen for preventive care (annual checkup) and when they are sick. Whether it's a young person with a sprained ankle or an older person with cancer (or vice versa), they both get the medical care appropriate to their condition without regard to their statistical risk. Insurance as we know it goes out the window because we aren't trying to keep costs down by only insuring the healthy (as the insurance companies do) but to budget for basic care for everyone, managing costs by early intervention and applying procedures that work. In the long run, we get healthier as a society because serious problems are spotted early through annual checkups.

And yes, the cost of Medicare (and the version intended for the rest of us) would have to increase to pay the real costs - no more cost-shifting to those with insurance. However, I could have my taxes go up by $6,500 a year and not see a difference if at the same time I no longer had to pay this amount for health insurance premiums. Similarly, my employer would feel no difference if their matching $6,500 went to the government instead of the insurance company. And these "insurance dollars" would be going much farther than they do now without the 30% profits tax that now goes to shareholders and CEOs of the company, to advertising and public relations, and to pay the salaries of the insurance company bureaucrats who stand between me and my doctor.

Not to mention the savings that would result if the government could negotiate the best pricing for drugs and services for it's customer base of 250 million members. Yes, big pharma (and it's investors) may see a reduction in profits and yes, even doctor's would likely see a decline in their income. Then again, their overhead would drop proportionately, along with much of the paperwork headache they now put up with. Imagine: a doctor who spent all his time dealing with his patients and not with the insurance companies. I expect they'd be willing to a reduction in salary in exchange for the reduction in bureaucratic headaches.

RE: Tort Reform
Yes, I agree that it needs to be dealt with. But there's no reason it needs to included in the healthcare reform legislation currently being considered. It's such a politically volatile issue that it would make passing any health reform bill practically impossible.

To my mind it would be like throwing in abortion as part of the reform debate - a guarantee to just drive us all farther apart along an emotionally charged and divisive issue. Better to pass health reform and then bring up tort reform. They are separate issues that don't need to be conflated.

Posted by Concerned Parent
a resident of Menlo Park: The Willows
on Aug 24, 2009 at 3:49 pm

Steve:
I won't claim to be an expert on forclosures or bankruptcies, and like you get a lot of information off the web. However, a few things to note: while it might be an ideal that academics be objective and unbiased, it is rarely absolutely true. I'm not alleging fraud, but two people can take the same data set and argue very different conclusions out of it.
A few thoughts for consideration in light of your comments:

-the line that 61% of bankruptcies had a medical cause required a definition of medical cause. If it says that bankruptcy with ANY medical debt is "medical cause", that is very different than medical debt being the major (or majority) of debt or medical debt above a certain threshold (e.g. $50,000). I believe the study used the least stringent definition which will produce the most attention getting number rather than perhaps the most illuminating. It would be very interesting to know the amount and distributuion of debt (e.g. percentage at $1000, $5000, $10000, etc.) as that might be telling about the assumed conclusion, that medical costs are THE driving factor of these bankruptcies/foreclosures.

-the percentages listed are again headline grabbing, but do not note that bankruptcy laws changed during the time between the two studies making a percentage comparison much more complicated and perhaps less relevant. At a minimum it would have been worthwhile to note the absolute number of events as well. It turns out that between 2001 and 2007, the absolute number of bankrupcies actually decreased substantially. It is possible (I'm not saying true as I think that multiple factors changed simultaneously making this very confounded and too complicated to draw definitive conclusions)that the number of medical bankruptcies (however defined) decreased, but the total number of bankruptcies decreased more, hence the percentage of medical bankrupcies went up. Again, while I'm not saying there should be anyone losing their home over getting sick, I don't want people losing their home over losing their job either and from this study, it's not clear which is a bigger problem. If this study overestimates the importance of medical bills as a factor in banruptcies, then expecting health care/insurance reform to correct the problem is not realistic.

The fact that 75% of these people had insurance also can have several interpretations. If they had insurance and that didn't keep people out of forclosure, perhaps there were other issues as well (if you're a Republican) or perhaps the evil insurance company found a way not to cover them (if you're a Democrat).

Keep in mind as well that the methodology used for the study was self reporting. Topics like bankruptcy and forclosure are very personal and it would not be at all surprising for people with multiple causes (e.g. divorce, gambling debts, job loss, addiction, and medical bills) to list medical bills as the cause appearing more sympathetic.

Just to be clear as well, I absolutely think we need changes to the health care system, but am concerned that if we are not careful about accurately defining the problem, we can't be accurate in fixing it.

You claim not to be an expert but you dismiss a study by four Harvard researchers who probably can legitimately claim to be experts. In addition, they had their study reviewed by at least several other experts, which was then accepted for publication in one of the most respected medical journals in the country. Why would the authors or the reviewers or the magazine publish shoddy research that would risk ruining their reputations? What justification or evidence do you have for infering that their results are other than accurate? You say that you "believe the study used the least stringent definition which will produce the most attention getting number" but you provide to evidence whatsoever that this is the case. Could it be that because the results disagree with your beliefs, you prefer to dismiss it out of hand rather than confront inconvenient truth?

I prefer to accept on face value that in this highly complicated problem, these results are as close to the truth as we can get and treat them as such. We don't need "absolute truth" here - a good ballpark number of what percent of Americans declare bankruptcy each year due to medical costs should be enough to let us say that our system is broken, particularly when the number of those in other industrialized countries who declare bankruptcy for this reason is essentially 0%.

Given that over 1.5 million households went into bankruptcy (in 2002) even if the results of the study are off by 100% (say it's only 30%, not 61%), then that means that 450,000 families experienced bankruptcy that year because they couldn't pay their medical bills. That would be a huge scandal in any other developed country and it should be a scandal here.

And it should be used to guide the debate - not swept under the rug because because of personal beliefs.

Posted by Concerned Parent
a resident of Menlo Park: The Willows
on Aug 24, 2009 at 5:41 pm

Steve:
Thanks for your comments. As far as insurance and risk stratification, I think we agree that there is a difference between putting everyone in the same pool (we all pay the same amount independent of health status) and having different payments based on perceived risk (sort of how it is done with auto insurance and credit). I have no problem with this sort of a system, I just wouldn't call it insurance. People also have to buy into the idea that the overall cost can be spread out over enough people. So while it may be that you are fine with more taxes at the rate of $6500/year assuming no insurance premium (this would have the added advantage of severing the disastrous link between health insurance and employment). I assume there is some point above which you wouldn't want to pay more taxes ($15K/year, $25K/year). For someone who is young and single, they may not be too excited about paying even the $6500 you mention. I think that is one reason you see the enthusiastic young voters who were so active in Obama's presidential campaign not so passionate about this issue, whereas the elderly are concerned that their benefits may decrease. The reality is that what Medicare can cover will likley decrease anyway, but people don't like feeling like they are losing something.
As far as prevention being the be-all end-all solution, I think these programs should be implemented, but I wouldn't expect savings. Proponents tout these as always producing cost savings, but again the literature is mixed. Ironically, if you find someone has high cholesterol at age 40, you may prevent them from having a heart attack and dying at age 55, but you will be treating them for another 30 years and they may proceed to have a heart attack at age 70. It's the right thing to do, but assuming it will result in net savings is not a slam dunk. The other question is how you mandate participation and encourage healthy behavior without being too intrusive. Educating the population on these issues is important, yet I've been underwhelmed with the US government's ability to educate people in general as things tend to get very politicized. Frankly, with regard to prevention, we would do much better as a society if we stopped subsidizing cheap unhealthy food and encouraged physical activity.

As far as doctors. If there is to be any discretion in treatment, I suspect that arguing with insurance companies will be replaced by arguing with the government about why the guidelines aren't appropriate for an individual patient. At some point, many will give up and decide it's not worth the effort (resistance is futile). It is easy to say that incomes would go down, however I would be concerned that over the long term, the effect would be to do with American health care what we've done with education. It would not surprise me to see doctors approaching retirement do so, others may choose to retire early, and others leave clinical practice. The best and brightest, idealistic or not will not take on burdensome debt with no realistic plan for paying it back. So the negotiation as far a salary will be between a government entity and what will be doctor's unions ( a natural consequence). Having directly observed the difference in responsiveness of private practice (fee for service) versus VA (salaried) physicians, independent of idealism, the responsiveness of the former blows away the latter.
Finally, the idea that physicians will just "do what works" strikes me a rather naive. Clinical evidence is quite varied and most studies have some deficiencies. They will also not tell you about a drug effect (good or bad) on an individual.

Posted by Concerned Parent
a resident of Menlo Park: The Willows
on Aug 24, 2009 at 6:19 pm

Steve:
I'm sorry if questioning someone out of Harvard offends you. Not being an expert in public policy does not mean that I lack scientific training or the ability to both read a scientific article or consider possible bias. Much is written about the bias of companies driven by profit motive. I would argue that many if not most academic reasearches (Harvard or not) have their own biases, they just may not be financial. Consider the following:

-The paper is published in the American Journal of Medicine, not the much more prestigious (and local) New England Journal of Medicine or JAMA (typical for high level public policy studies). The AJM has long been a second-tier journal within the medical community. That may tell you that this study has issues. This also likely means that the peer review is not as strict as journals need to fill the pages and the top stuff will go to NEJM and JAMA.

-While you tout Harvard, the affiliations are out of Cambridge Hospital, again within the Harvard system, the second tier of academics (consider that the Harvard system includes Massachusetts General Hospital, Brigham and Women's Hospital, Beth Israel Deaconess Hospital, and several Institutes as well).

-The study itself (at least the abstract) notes that it used a conservative definition of medical bankruptcy, specifically if any of the following applied: 1)debtor listed it, 2)any illness was involved, 3)magnitude of debt. Having cast this wide net, they interviewed approximately half. Note that this interview process could not be done randomly as people had to agree to do so. In fact, the definitions were so broad as to include those who had 1)missed two or more weeks of paid work as a result of illness, 2)had medical bills in excess of $1000 over a two year period and filed for bankruptcy, or had other serious illness which is very broadly defined. To be properly controlled and to really address the issue, it would be very worthwhile to know how many people had those same conditions and DIDN'T file for bankruptcy or lose their house.

-Of the three authors on the cited papers, two are physicians on the record as strongly advocating for a single payer, government run health care system. How likely do you think it is that they would publish data either contradictory to their earlier works or that didn't support their position? This get back to not the data per se, but the interpretation of the data. A major criticism I had over many decisions of the Bush era related to his arriving at a conclusion then only seeing data that agreed with that conclusion.

Again, I'm sorry if my lack of blind acceptance of the paper at face value (and it's amplification of the intended "take away" by much of the media) upsets you, but I will contend I am not saying it's OK to have people going bankrupt or losing houses over medical bills, I'm just not convinced that this study (as best as I can decipher it) or the subsequent press around it, really informs the debate.

Yes there is a limit to how much of a tax increase I'd pay to have a universal health care system. I just look at other similar countries who pay half what we do for better care and I ask why we can't do what they do? Better care - universal coverage - reduced cost. What's not to like about this picture?

It isn't inevitable that health costs have to keep going up. The fact that they have been has actually been extracting a hidden tax from both of us - salary increases that we would have otherwise received in recent years have been eaten up by increased premiums. Because the money goes to the insurance companies, it's not called a tax but it's still money out of my pocket.

You're right that young people won't welcome having to pay into a system if they're charged the same as us oldsters who are making the main demands on the system. So the health care tax may have to be progressive based on a combination of age and income. The fact that 45 million new members will be contributing to the system (plus their employers) means that the revenue side of the equation will also increase with expenditures. Again, I get back to the fact that most other industrial countries have figured out how to provide better care for all their citizens at less cost. I don't want to believe that America is less capable than other countries at solving these problems. Perhaps if the Cold War hadn't sensitized us so much to the word "socialism" we'd be able to view things more rationally.

I agree entirely with your observation that "with regard to prevention, we would do much better as a society if we stopped subsidizing cheap unhealthy food and encouraged physical activity." Gets back to campaign finance reform that would prevent the agribusiness interests from buying off our Congress people.

When I said the doctors can achieve cost saving by applying procedures that work" I was referring to the part of the bill that would appoint a committee of health care professionals who would evaluate the efficacy of treatments, procedures, drugs, etc. Only those that have been demonstrated through rigorous studies to be effective would be covered under the single payer system. This is the part of the cost savings that can be achieved by eliminating unnecessary/ineffective treatments.

Again, it requires a faith in our best scientists and officials to be able to discern what works and doesn't. For those who place their faith in alternative medicines, we may need additional research but, in the end, we go with the best information our medical schools and institutes can provide. Beyond that, private insurance plans would be available for those who want coverage over and above what the govt. plan provides. As is the case in other countries with single-payer plans.

Please enlighten me if the 1st tier of our medical research establishment has something different to add. If there's a better study out there I'm certainly open to revising the numbers we use in the debate. Until then, it makes sense to go with the best study available, warts and all.

But even if these 2nd tier researchers, reviewers, and publication are flagrantly letting their biases rule, it doesn't change the bottom line that our healthcare delivery system is failing us if even 1% (15,000) of families are forced into bankruptcy by medical bills. And certainly you wouldn't argue that the number is less than 1% would you?

Posted by Concerned Parent
a resident of Menlo Park: The Willows
on Aug 25, 2009 at 10:07 am

Steve:
Some additional thoughts/comments:
1)better care/lower cost-what's not to like. I guess I'm not convinced that it's that simple. I suspect the health care consumer does sacrifice something (longer waits, denial of some care, etc.). Most of these things are a balance. At present, the US is skewed toward a do everything immediately approach. This likely does result in some waste and as a society we need to be able to wait with back pain for the MRI or CT or just get pain meds empirically. Our culture and expectations will require some major adjustments to go here (see the latest from the Repubs about "Senior rights"-basically locking in the problems that got us here). On the other hand, there are unmeasured costs/taxes associated with a capped system (which is absolutely necessary if you want to contain costs). This is done with taking people's time as they wait throughout the system. Check out the ER at any county hospital and this will be borne out. So I would argue that if you take:
a)full coverage
b)no additional cost
c)maintenance of current standards of medical care
you can get two of the three but not all three.

2)better outcomes for less money. This is often touted and again I'd prefer to look at methodology rather than one number. For example, looking at straight stats for infant mortality, Cuba does much better than the US. The annual expenditure per capita for health care is on the order of <$500. Sounds great as a sound bite. But..it turns out that the abortion rate in Cuba is significantly higher than in the US, particularly for late-term, high risk pregnancies. It turns out that within the Cuban system, the concept of informed consent is quite limited and patients are expected to do what the MD says. It turns out that infant mortality numbers are something the government tracks with great interest and touts as an indication of the superiority of their system. Now in the US, if there is a 30-week premature baby delivered, that baby may be treated in a very expensive neonatal intensive care unit and may die anyway. Now rather than being counted as a "stillborn" as it might be in Cuba (because it never survived childbirth), it will be counted toward infant mortality as well as having run up a large bill (these cases can easily cost $500K-$1M). Since the numbers are (thankfully) pretty low (3-6 infant deaths per 1,000 live births), an individual case can make a significant contribution. Since these deaths occur at such a low age, they also markedly drag down life expectancy estimates. So "better medicine" could result in a 3 month improvement in someone with lung cancer, but this will minimally impace life expectancy stats (since it usually affects those over 50), whereas a significant number of young deaths (say from car accidents, gun shot wounds, etc.) can markedly bring down averages. One could argue that we could move toward universal prenatal care and stop intensive neonatology, understanding that between the high risk pregnancies in the US from infertility treatment, teen pregnancies, etc. there will be some babies that won't survive and not count them as live births. The result would be less money spent and "better"stats, though we might not like the result.
3)Costs won't go up- one issue not often discussed is why costs go up. While it is easy to blame doctors, hospitals, insurance companies, and so on, the flip side of that is the cost of medical progress. Presumably as a society, we like medical innovation. The options available for treatment of heart attacks, strokes, many cancers, are light years ahead of where they were 30 years ago, but they are expensive. It will be a challenge to balance cost containment with innovation as they pull in opposite directions. For drug development, I've seen estimates that it costs $1.5 billion and takes 10-15 years to develop a new drug. As the opportunities become smaller and the conditions more challenging and FDA requirements more stringent, I would sadly expect this number to go up. Now whether costs can be kept to the level of inflation as opposed to running ahead is a different issue. If you go to the UK, there are new cancer drugs that aren't covered which is an example of not adopting new technology. Can new approaches/technology cut costs? In some cases perhaps, but history tells us that usually costs go up. Something else in this vein, is that the US has been the major place for development of new drugs (because we pay more than other countries). It is unclear to me what the new paradigm will be but I suspect that the world will conclude we've reached a point of diminishing returns in terms of pharma and that may be that. Good for you if you have a treatable condition, but not if you don't. Ideally, the market could be skewed to incent pharma to develop truly novel drugs rather than me-too drugs in large markets, but that's for another day.
4)Medical bankruptcies. I would disagree that any study, no matter how flawed is better than nothing, however, rather than looking in the American Journal of Medicine, I would scour the health economics literature. From what I can tell there, there is no study reporting anywhere near even 50% of bankruptcies/foreclosures resulting from medical bills. What numbers I could find from a brief search show that 13% of filers had medical bills of >$10K, 40%<$5K, 20%<$1K. I'll agree that any number is too high and also that the hypothetical 1% is very likely lower than reality. My point, though was that there is a big difference between 1% and 60%. If you are talking about 15,000 people, that may be too many, but it likely pales in comparison to the number of people going into foreclosure or bankrupcy as a result of the economic downturn. The conclusion there is that if you focus on medical costs as a major force behind bankruptcy, and make a major change based on that and don't take care of something else (The economy) which may play a much larger role, you are less likely to alleviate the problem. One more note regarding the study. If I did a parallel study and looked at the number of people who owed taxes and went into foreclosure or bankruptcy, I suspect I would find a significant percentage. Would I then conclude that this was the primary cause and therefore completely revise the tax code? At a minimum, I'd want to know how many individuals owed taxes, yet didn't go into bankruptcy, before making any conclusion.

Thanks for hanging in there this long. This is an important debate to be having.

Not one person in Japan, France, Germany, Canada or the United Kingdom (to cite just five) went bankrupt because of medical bills last year. That fact alone demonstrates the failure of our health care delivery system where a minimum of 15,000 (your preference)up to perhaps 900,000 (the most-rigorous current study) bankruptcies were due to illness or medical bills. No one should have to loose their home and life savings because they are sick.

Other countries less well off than ours have recognized this and have instituted health care systems that keep their residents healthier than ours, at less cost than ours, with considerably less bureaucracy than ours. Surveys show that in all cases, their citizens are much happier with their health care than are Americans. And I'm not including Cuba in the list of developed countries with superior health care.

T.R. Reid, a former reporter for the Washington Post, was on Fresh Air last night and talked about his book recounting his experiences with health care systems around the world. I found this summary he wrote of his research that clearly makes the case for looking oversees for a model that could replace our broken system. It's only 3 pages long. Read it and see if you agree.Web Link

I guess we won't come to agreement on the AJM article, though their numbers seem certainly credible. Half the people they interviewed reported that illness or medical bills drove them to bankruptcy and the researchers' analyses of the their financial documents, filed with the courts during their bankruptcies, supported this conclusion. I don't see how you can intuit that these individuals were not telling the truth or the researchers were being less than objective in their study.

Posted by Concerned Parent
a resident of Menlo Park: The Willows
on Aug 25, 2009 at 2:00 pm

Steve:
Thanks for the link. I'd agree with the take away, namely that it would be worthwhile looking extensively at what the various pros and cons of other systems prior to putting forth a major new initiative. For better or worse, there has been an amazing rush to get something done, anything rather than looking in detail. From a quick read, I would be a bit concerned that there are various anecdotes that are used to make a point and I have to wonder if the points are then generalizable. For example, the fact that there are examples of innovation outside the US does not necessarily tell you what type of system encourages it more. The fact that the cost of a single test was brought down in Japan by cost controls tells you that it was possible in that instance. That doesn't tell you if there were tests taken off the market as a result. The other issue in looking cross system, is it may be that based on volume, the cost of radiologic procedures may be brought down and that certainly makes sense (more scans to amortize the large initial capital expense over). The trumpeting of 700,000 medically related bankrupcies is someting else I would take issue with while absolutely agreeing the number needs to be lower.
I'd also agree that we have a hodgepodge of plans. The point about the VA being like Britain, some private insurance like Germany, etc. is a good one. Of course all that raises the real issue which is what are the implications of all this information? To me, it gets down to what are the priorities we want from any system (full coverage, cost control, elimination of exclusions, etc.) and what are honest numbers about how much it will cost. That should then drive the best system as opposed to saying here is a plan that will do everything.
From my perspective, there are some easy first steps that should be easy to do, independent of political persuation (for the record I'm an independent and am not particualrly fond of either party and the bipartisan bickering).
1) separate the relationship between employment and health insurance. Whether with tax incentives/credits or whatever. This along with portability (we can do it for phone numbers) and increased competition should keep costs honest.
2)In terms of competition, it seems to me that allowing the selling of insurance across state lines should be a no-brainer. We do it for car insurance, certainly it's in the states' interest to do it.

3) I would add on tort reform as I think this has the easiest shot at reducing costs in both the short term and in a major way if the culture of defensive medicine can be broken and could also allow real error analysis and improvement within any medical system.

Finally, to go off on a totally different tangent but getting back the difference between association and causality. While numbers are continually put out stating that we pay more for health care yet have poorer outcomes, within that is an underlying assumption that health care is the major cause of outcomes like life expectancy. there was an interesting analysis done in 2006 that looked at life expectancy numbers and noted that we have amazingly high numbers of automobile accidents and homicides (again culture rears its ugly head). We are 12 times more likely than the Japanese to be murdered and nearly twice as likely to be killed in auto wrecks. In their 2006 book, 'The Business of Health,' economists Robert L. Ohsfeldt and John E. Schneider set out to determine where the U.S. would rank in life span among developed nations if homicides and accidents are factored out. Their answer? First place. It may be that we can spend less and do just as well at treating disease, but it might also say we need to do something about car safety, homicides, and something we agree on generally health lifestyles. It may be that we spend quite a bit on pills for diabetes, but continue to encourage food choices that set people up for it.

As far as the AJM article, I've previously stated many methodological issues with it. My conclusion from the study as described is that it tells you that it is common for people who file for bankruptcy to have outstanding medical bills. By the reported methodology, someone who had a $100K gambling debt and an outstanding $700 medical bill would have been reported as a medical bankruptcy. If I see a headline that says 61% of bankrupcies (700,000) are a result of medical bills that is very different than one that notes that 13% of people declaring bankruptcy had more than $10,000 in medical bills outstanding. I'm not in favor of either, but the hyperbole of the former detracts from the message.

Posted by Another interested person
a resident of another community
on Aug 25, 2009 at 4:01 pm

Concerned Parent:

I've been participating in this "debate" on another board and there's no winning or losing. I've yet to see anyone say eureka and change their opinion.

My disappointment is that neither side appears to be willing to compromise. Each side seems perfectly content to let this moment pass without any reform rather than take some reforms and come back another day. In medicine, we have a saying for it - "perfection is the enemy of good." Even Bill Clinton, who came away empty handed in 1992, has said we are better off with a half a car load than none.

Both sides agree that getting rid of pre-existing condition exclusions (at least for some kind of basic policy), selling across state lines, tax incentives to help offset the cost of premiums and tort reform are acceptable reforms. Why does each side insist on elements that the other side cannot accept and ignore reforms where there is mutual agreement? We should expect more of our elected officials.

Posted by Concerned Parent
a resident of Menlo Park: The Willows
on Aug 25, 2009 at 8:00 pm

Another interested person:

I agree. That's why I don't like either party. The Dems are demanding major change or risk getting nothing. The Repubs appear to want nothing. The elements you raise would all appear to be no-brainers and doable.
The reality is that the country is not sold on the all-in-one package and doing it in a rush does give the impression that the Dems don't want people actually looking at the details. I would have to think that removing the pre-existing condition option, allowing competition across state lines, and severing the link to employment would increase competition, allow health consumers to actively be consumers (i.e. comparison shop and demand value), and remove the current penalty for getting sick. I would love to see tort reform as well but have no illusions since that hasn't even made it on the table.

I'm cynical but I'm betting that Obama will do anything he can to get something, anything. It may be that there is something with co-ops and a public option to kick in later. If the Dems really continue their fighting, it will be an amazing display of cutting off one's nose to spite one's face as they can't really pin this on the Repubs (as obnoxious as they are).

I agree that perfection is the enemy of the good and that to hold out for everything risks losing everything. Removing pre-existing conditions would be big step forward. Removing rescisions also is important. Fortunately, reading the transcript of Anna Eshoo's telecon last week, it sounds like both of these are in the House committee bills that have been voted out of committee. Not sure if she said they were also part of the Senate bills.

I'm not a fan of allowing competition across state lines because it does nothing really to eliminate the profit motive from the health care equation (upward of 10% of each dollar that goes to shareholders and CEOs) nor does it reduce the inefficiencies inherent in having hundreds of insurance companies, each with their own rules and coverages that cause needless expense & headaches for doctors(20% of the private health care dollar goes to administration). Say what you will about Medicare, with only 4% of each dollar going to administration, it's the most efficient delivery system out there.

I don't know much about tax incentives to offset premiums. I'm hesitant though because it does seem that this is an expense to government that either increases our deficit or results in a cutback somewhere else. It also doesn't help control costs of insurance, which is one of the major problems with health care and the main reason we have to pass some bill (any bill!?) that effectively slows ballooning costs.

BTW - on the Morning Report there was a segment on how Lyndon Johnson got a reluctant Congress to go along with his Medicare proposal in 1964 by hiding the long-term cost. As is the case now, he felt that seeing such a large number would have scared away too many supporters. In the end the bill was passed and is now one of government's most popular and successful programs. Seems we're in the same situation today.

They also played a short clip of Ronald Reagan before he was even governor, railing against the program because it was "socialism that would take away our freedom to choose". The speech helped establish his conservative credentials and put him on the road to the White House.

Posted by Concerned Parent
a resident of Menlo Park: The Willows
on Aug 26, 2009 at 10:44 am

Steve:

I see a lot of these things as a balance. Administration can mean lots of things. The good side of administration for either a private, for-profit insurance company, or for a public government program is assuring claims are valid and avoiding fraud. Conventional wisdom (and I won't claim to have studies to support it) is that there is more fraud with Medicare than with private insurance. On the other hand, the bad side of adminstration is when it is used to aggressively deny care. The easiest solution is to have one size fits all, no choice, controversial items paid for based on politics. This is where I worry about the culture of the US: what to do about abortion, what to do about infertility, what to do about erectile dysfunction, etc. Already we see different disease advocacy groups lining up to make cases for research dollars for their disease. One might forsee a similar process for reimbursement. Administration can also include organization and coordination leading to efficiencies. Giving the US population multiple choices about what level of coverage they want raises administrative costs. Is it worth it? There are certainly lots of opinions. I don't, per se, have an issue with private insurance companies making a profit, depending on how it's done. Avoiding patients with risk, recission, etc. are not the ways to do it, but being more efficient, negotiating packages with hospitals, etc. that result in cost savings for the people covered may result in savings overall. Similarly, in some of the models for health care delivery, if a hospital gets a single fee for a procedure and is able to be more efficient (coordination between the MDs, nurses, pharmacy, etc) they keep the difference as profit. This serves as an incentive to make care more efficient. Should that profit be discouraged? From what I can tell, the government's approach to cost containment is to bully and I wouldn't imagine this would be any better with a single payer or public option.

Back to LBJ and underestimating the costs. I find it ironic that such a story would be used to justify a similar program. Medicare is popular because if gives seniors more than they pay for. The cost of this is seen in the $30 trillion unfunded liabilities with the expectation that the fund becomes insolvent within a decade. Fannie and Freddie were popular too until they weren't (the bill came). Add to that the fact that because Medicare underreimburses, there is cost shifting within the medical system (a tax but one that gets blamed on the private system- brilliant politics but not sustainable). Of course its popular. But it's not sustainable. To take a program that on average loses money for every individual (pays out more than it takes in), you can't make up the difference in volume. I suspect that if Medicare were run in a revenue neutral way, people might be less satisfied with it and that is why we're seeing panicked seniors worried about benefits being cut. The Republicans are fanning flames by trying to guarantee that seniors continue with the same unsustainable deal.
So if I follow, we should lie about programs to get them enacted, get people hooked on government subsidies (Medicare is not self-sustaining), then expand them with more lies about the cost. This sounds almost as cycnical as the Republicans.
We have analagous problems with public emplyee pension programs here where contacts are arrived at with generous future payments and retirement benefits. The result is an increasing amount of revenue goes to pay people who are aren't performing work meaning the public gets progressively less for the same tax. The result with both expanded Medicare and rising pension obligations is that there will not be enough people to tax in this country to pay for it all.

Very good points. I hadn't appreciated the amount that Medicare is underfunded - that has to be factored in to whatever plan Congress passes. Clearly, the public plan is experiencing the same escalating costs that private insurance is. If we can't get costs under control, both systems are going to implode.

I just read that the cost of private plans is expected to go up 10.5% next year and that drugs will rise 9.3%. I'm sure the insurance companies are passing these increases along to me and my employer and that I'll be "taxed" for them. Yet Medicare doesn't pass along the full cost of the increases, partly because the Medicare crowd by and large isn't in any position to afford it. I know my retired mom would experience financial pain if she had to pay this increase, especially since Social Security is not going to get any Cost of Living increase next year.

Tough problems. Yet I look at other countries who are paying much less than we are, insuring everyone, and getting better health results in most cases. Why can't we learn from their examples to solve our problems.

Switzerland especially seems worth looking at. Just 15 years ago they were in our boat with escalating costs, numerous private insurers competing for business, and many uninsured citizens. Their legislature passed a plan (with a single vote making the difference!!) and now they have a single plan, administered by the same insurance companies, that is controlling costs and delivering better care to all their citizens. They can do it. Why can't we?

As for lying about costs to get Medicare passed: I mentioned it because I believe that even with it's problems, Medicare is a very good program. We'd be in much worse shape today (certainly the elderly would be) if Congress at the time hadn't had the courage and foresight to pass it. If it took a bit of political gamesmanship to accomplish it, so be it.

I like to think that people (and Congress) are rational and act in their rational self interest but it seems like they too often let emotions rule their actions. Then and now, fear seems to be the biggest impediment to change.

Had we passed a broader public health care plan at the time, I think we wouldn't have seen the escalating costs of the past 20 years. We'd be like other industrialized countries - arguing about the appropriate cost/benefit ratio for health care - but within the 9 to 11% of GDP that other countries spend, not the 16% of GDP that we're currently spending.

Posted by Concerned Parent
a resident of Menlo Park: The Willows
on Aug 26, 2009 at 1:43 pm

The thing about public policy (Medicare, stimulus bills, etc.) is that there is no way to do a controlled experiment. Even absent that, I'd agree that Seniors have benefited significantly from Medicare. As have doctors at least in the early years. On the down side, one result is the decoupling of consumption and purchase of health care and learned behavior that there are no limits. Culturally this needs to change as does the expectation that we can completely avoid risk (malpractice suits for bad outcomes anyone).
One could also argue that with a broader plan there would be rationing.
I have heard generally positive things about Switzerland but haven't investigated in detail. One question that needs to be asked for any of these plans comes back to culture/homogeneity/heterogeneity. It may be easier to do a one size fits all for a smaller more homogeneous country. I'd be interested in having a few different states pilot some of these systems and do a real comparison before taking something national. I'd also love to see the link of insurance to employment disappear.
As far as the better results, I'll also get back to social issues that are reflected in health outcomes. if we have 33% of the population being obese and an epidemic of diabetes on the way, our health outcomes are going to decrease no matter what we spend and how we spend it. We can argue to spend more on prevention, but some of prevention relies on personal responsibility which is very difficult to legislate. The result being that if I'm a 55 year old overweight diabetic in need of coronary procedures, I'll benefit from a universal coverage system, whereas if I'm a 27 year old fitness freak who watches my cholesterol religiously, I'll pay more into such a system.

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